9 June 2011

Could the press act as regulators for the health service?

I have been thinking about this article from Health Policy Insight

I was alerted to it by a twitter exchange between the outgoing chief executive for Midstaffs and one of the journalists who has spent what must seem like a high proportion of his life covering the Midstaffs story.
The Health Policy Insight blog makes the point that regulation does not always do what it says on the tin, and given that in a series of recent NHS scandals the press have got to the problem before the regulator, he wonders if we should just forget about regulation and give the money to the press to do it for us.
Here is his solution.
Having read many of the witty and incisive pieces written by this writer, it is quite likely that this is a piece of kite flying, but it is interesting that both the CEO and the journalist were very taken by the idea.
Abolish poorly-functioning national quality regulation, and give the money as a subsidy with a range of conditions to local newspapers. A small sum needs to be paid to some independent regionally-based staff, to monitor and follow up on the output.
Regulation and the Stafford Inquiry
Like the Journalist and the CEO I have also devoted a lot of my time to days at the inquiry, or reading transcripts. I do so because I am interested in the challenge of regulation, and also because I have become fascinated by the many important issues that this case has raised about the press, and the real difficulties the press may sometimes face in painting a fully rounded picture. I have learnt a lot about the many sided and often un-graspable nature of “truth” in this process.
In my opinion the impetus for the public inquiry at Stafford came from four different directions.
·         Obviously there is the hurt of the individual campaigners and their need to make sense of their experience. This need quickly became enmeshed with the needs of politicians.
·         There is the press and their sense of duty and financial commitment to a  powerful public interest story
·         Then there is the political impetus. The story was an apparent opportunity to prove the “failure of the NHS“ and to prove the need for the Government’s now teetering health reform package.
·         And then there is the question of how to regulate the health service. It became abundantly clear that regulation, as it was at 2006-2007 was not doing its job. Regulation should either have been able to flag up problems, or give the health service a clear defence against disproportionate criticism. It could do neither. We are not looking back to a golden age of regulation in the past. Regulation has been developing for decades, partly as a response to political need, but this slowly evolving art has not yet reached a stage where we know it can do the job.
How Regulation is developing
What is clear to me is that the health service has learnt a huge amount about regulation as a result of the complex but demonstrable regulatory failure at Stafford. The service has responded with quiet reforms so that the regulatory systems and tools that we now have are unrecognisable from the systems as they were in 2007.  I am not sure that these major changes are yet widely understood. I would advise reading the evidence and statement of Richard Hamblin who served in both the Healthcare commission and the Care Quality commission as a good starting point on this.

The new tools are promising, but a crucial element of this new approach to regulation, is the recognition of the limitations of the statistical systems. The systems matter, and matter a lot, because they are the way in which we can build a framework to keep NHS standards national. It is clear from David Cameron’s recent speech that the government is depending upon them for this purpose. The practitioners, those who understand the systems best, know that what we have is at the very most a warning system. The data is subjective, quality of coding matters, there are few people with the skills to do this well, and human error occurs. As investment in “non essentials” is squeezed then this is an area of the health service performance that may well suffer.  What the statisticians tell us plainly is that simple statistics cannot be used to demonstrate that a hospital is “failing”. The League tables so loved by the press for their simplicity and dramatic effect should now be a thing of the past.
The CQC new philosophy of regulation combines use of the indicators that may flag up potential problems with skilled people on the ground to delve into areas of concern and to help hospitals begin to be able to identify clearly where they can do better. The weakness that the CQC has now, and I think this is demonstrated by the Winterborne case, is that there are simply not enough skilled inspectors to do the job. There is a serious recruitment problem.
The role for the press and the public.
The thing which I think appealed to the CEO and the journalist about the idea of the press as quasi regulators, is that the CEO has said there is a need for thousands of pairs of eyes. It is everyone’s responsibility to take care of the health and care services. We all need to raise concerns. The question that remains is what is the best way to be able to do this effectively?
One thing that was abundantly clear from the Midstaffs case is that the complaints system within the hospital was dysfunctional. It was quickly reformed and is or course being reformed again now.
Complaints directed outside the hospital were effectively useless, as many different people ended up with one or two pieces of paper on their desk. -Never enough to form a pattern.- None of this connected.
The need for an effective patient participation vehicle was of course completely recognised and the LINks system was in the process of forming as a replacement to earlier vehicles for participation when the Midstaffs problems kicked off. This small group of willing and well meaning volunteers was not in any way equipped to deal with the huge problems the Stafford Campaign group brought with them. Having witnessed some LINks meetings at this period the volunteers who might well have done a good job in other circumstances were paralysed by the truly astonishing level of animosity that these meetings generated. It is perhaps useful to mention that the LINKs system, which was crying out for more public involvement received virtually no support at all from the local press, and did not become visible until the press were in a position to criticise them.
So the channels which should have led to constructive engagement between the public and the hospital over the problems that existed failed, and we were left with a situation where the press perhaps rightly saw it as their job to side with the pressure group against the hospital. The hospital found itself on the receiving end of literally thousands of negative articles, ( I have boxes of them) which may arguably have contributed to the loss of staff morale, patient confidence and to the financial problems of the hospital. Energy that could have gone into resolving the problems that existed was diverted into simply surviving the barrage.
Changing the game
The public voice needs to be heard –but how?
I think there are a number of ways in which this has already been tackled:
·         The Hospital pioneered comfort checks, which means that potential “complaints” are tackled before they ever reach that point.
·         The hospital brought in simple boards for patients and families to raise suggestions.
·         The board meetings are all held in public, and actively encourage public engagement.
·         Training for staff brings the patient experience to the forefront.
·         The Trust holds meetings on a range of issues which are all designed to help the public make their voice heard.
·         NHS Choices was set up by the DOH and SHA and already functions as a way of channelling complaints and concerns  through to CQC and presumably to the hospitals.
·         LINks  in Stafford got adopted by County Council, Not sure what impact this has had, but it removed the temptation to use it as a political football.
·         Healthwatch will have a clearer integration path to CQC which will assist to ensure all problems channelled into a place where they can be collated.
·         One element of the CQC system which is still very new, but potentially game changing is the QRPs. Hard data, particularly hard data that tells you what you think it does, is hard to find. For it to be of any value it requires skilled people spending time collecting data, Some of this is essential, but it is at least for the time being politically unpopular. The QRPs will make it possible for many sources of “soft data“ such as patient complaints and press stories to be logged in a way that would give some idea of patterns or clusters of complaints.  If this takes off then the press will find that there is potentially more of a response to their efforts than was ever possible in the past.  This would help everyone. If low level complaints can be heard there should no longer be the necessity for vocal and potentially divisive and delaying campaigns. So with or without a “quasi regulatory” role the press should be able to play through the QRPs  a more effective role in helping to express people’s concerns. Richard Hamblins evidence is again helpful on this matter.
Could the press do more?
To go further, to actually direct public money at the press to help regulate the NHS and other services is a genuinely interesting proposal, but I think this raises some rather serious questions about what the press is actually for and how far the press is willing to modify their role.
If you had asked me this question 20 years ago I would have said that the local press was there to serve the good of its community, but 20 years of observing the press in practice has made me question this.  
What the press perhaps has to offer is the skills of individual journalists in assisting individuals to make their points. Many journalists would be able to do this job very well, and the community would be better for it. But does this sit comfortably with the role of the press?
A regulator – and anyone who would want to perform a regulatory role has to be accountable. Their first priority is to see clearly the truth of a situation from all sides. This will generally mean slow, careful research, the checking of facts, and making it possible for different people to give their side of a story.
The press – at least the press as we know it does not do this. The role of the press is to tell interesting stories and to sell papers and advertising space. We are dealing with businesses trying to make a profit in a market that is under some fairly extreme pressure.
Journalists do not have the luxury of time to research carefully. They must tell their story in the required number of words, in time to get the paper to press.
Papers belong to wealthy men, who have friends and have political allegiances. Running papers means attracting advertising revenue, and people who pay well are obviously important to any proprietor. Public services, and especially the NHS is deeply political. Journalists are hired and fired for a variety of reasons, and unless journalists acting as “regulators” can be protected from the subtle pressures to say “the right thing” they could not carry out this role objectively.
Beyond that there is the whole way in which the press sees the world. The press likes stories where people are shocked or disgusted or angry. They like stories of distress and human suffering. They like blame and retribution. These are the stories that set the tills ringing. Other stories, less dramatic but equally important do not have the same weight.
Just as an example, I spent 5 years trying to interest the press in the complex issues that were addressed in the Labour party White paper on social care, and are now going to be addressed by the Dilnot report.  These are issues that cause very real hardship and distress to thousands of families, but because I was interested in seeking solutions to the problem, and was working with people to do so, this was not really a very interesting story to the press. I was not prepared to blame anyone for the problems that I had personally encountered, and therefore there was no conflict to make this important story entertaining.
If we were to direct public money at the press it would need to carry the requirement for them to deal with stories, sometimes, complex stories, in which they might not actually be very interested.
So is the whole thing impossible?
Perhaps not.
Papers as we know them are at the end of their life. All journalists accept this. When papers go the influence of the powerful men who run them will go too. This influence is already waning as the internet continues to bring together clusters of individuals who work together to make their voice heard. Papers are already losing their monopoly of “the truth”.
But this is not enough. In five to ten years the press and the internet will have changed beyond recognition, but the skills that good journalists have to offer will still matter.
If we do go down the road of GP commissioning and shadowy new providers then it could be that the press really will have a vitally important role to play   When providers are not open, then real investigative journalism will be needed.
“The advantages for local papers are that a subsidy to deliver adequate health coverage would reinforce their curiosity about local provider (and indeed commissioner) performance. There are many good stories to be had.”
The internet is bringing a quiet revolution, the democratisation of information. NHS Choices is a part of this. But more need to be done to make this quieter more collaborative approach work for people. This kind of development is a tool for a healthier democracy.
Journalists have a role to play here. If everyone is helped to use their voice, if we get beyond the paternalism of the press in its current form, then there will be thousands of stories that at present we simply never hear.  Good journalists could help with the task of making these visible. If they really help to give people a voice they can play a part in transforming our communities.
The Problem of “Truth”
The writer makes the assumption that the libel laws we currently have are enough to ensure that the truth will generally be told by the press. My perceptions of the Stafford Story show why in this particular case – which may well be unique I would have deep reservations about this. Truth is not always a simple matter. That is why many millions of tax payers money are now being spent to find out what really did happen at Stafford, and even when we have with of hundreds of hours of clear evidence and witness statements to go on then we find that there is still some surprisingly radical differences in the interpretation of the “truth”. 
For the press to be able to play the part that I would like it to play in our communities, either as a “quasi- regulator” or simply as good newspapers I think there are some simple changes which need to happen.

This is perhaps most easily illustrated by looking at a single element of the Stafford Story.
The single biggest problem with the reporting of the Stafford Hospital story comes from the fact that the excess death figures were presented as authoritative fact, when in my favourite euphemism of the moment, they are “not an entirely uncontested version of events." They were something which came from a document that has been deleted, under circumstances we now clearly know, leaked by a person who has not been identified, based on data acknowledged by virtually all informed opinion to be seriously flawed, and using a calculation which the creator of the data system has clearly stated to be inappropriate. If this is fact it is certainly not fact as I recognise it. – but due to the extreme complexity I am not yet satisfied that the PCC would see it as a clear infringement of the editors code.
I am very easily satisfied. All that I ever required from the press is clear attribution. If they had begun with the premise all “facts” must be traceable back to their source, I do not believe they would have been tempted down the road they travelled. Repeated quotes of “hundreds of deaths” would be so much less appealing if it was immediately followed by the details of what was known and not known about this "information".
Health policy insights says
There are also the pitfalls of bias, grudge-settling and other such drivers – but the press are used to dealing with these motives, and to presenting both sides of a story. More to the point, the British press knows that it is subject to some of the world’s most stringent libel laws, in which absolute truth and the public interest are key defences.
This Is something that I would really like to be able to rely on, but at the moment I do not genuinely believe that I can do so.
The press is in the dock now, over a growing range of different abuses. All institutions must now come under scrutiny and it is the turn of the press. Maybe now is the time to set the ground rules for giving us the press reform that I believe both most good journalists and the public want and need. The Stafford Hospital story gives us valuable pointers to the reforms we should be looking for.
 I could be reassured if
·         journalists would always produce their source material if requested for it,
·         in the event of serious disagreements over the interpretation of “truth” that one could call upon an impartial expert tribunal to act as an “appeal court”,
·         in the case of science based stories these tribunals would be expected to call in people who understand the material in question,
If this were done then I would genuinely welcome the major improvements that this would bring to journalistic practice, and would welcome an appropriate role for the press in helping people hold public services to account.